C-reactive protein in simple community-acquired pneumonia

Impact of Guideline Adherence on Outcomes in Patients Hospitalized with Community-Acquired Pneumonia (CAP) in Hungary: A Retrospective Observational Study

Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide. This retrospective observational study evaluated the antibiotic prescription patterns and associations between guideline adherence and outcomes in patients hospitalized with CAP in Hungary. Main outcome measures were adherence to national and international CAP guidelines (agent choice, dose) when using empirical antibiotics, antibiotic exposure, and clinical outcomes. Demographic and clinical characteristics of patients with CAP in the 30-day mortality and 30-day survival groups were compared. Fisher’s exact test and t-test were applied to compare categorical and continuous variables, respectively. Adherence to the national CAP guideline for initial empirical therapies was 30.61% (45/147) for agent choice and 88.89% (40/45) for dose. Average duration of antibiotic therapy for CAP was 7.13 ± 4.37 (mean ± SD) days, while average antibiotic consumption was 11.41 ± 8.59 DDD/patient (range 1−44.5). Adherence to national guideline led to a slightly lower 30-day mortality rate than guideline non-adherence (15.56% vs. 16.67%, p > 0.05). In patients aged ≥ 85 years, 30-day mortality was 3 times higher than in those aged 65−84 years (30.43% vs. 11.11%). A significant difference was found between 30-day non-survivors and 30-day survivors regarding the average CRP values on admission (177.28 ± 118.94 vs. 112.88 ± 93.47 mg/L, respectively, p = 0.006) and CCI score (5.71 ± 1.85 and 4.67 ± 1.83, p = 0.012). We found poor adherence to the national and international CAP guidelines in terms of agent choice. In addition, high CRP values on admission were markedly associated with higher mortality in CAP.

Recurrent severe respiratory infections with low CRP secondary to autoimmune IL-6 deficiency

C reactive protein (CRP) is an inflammatory protein that is often used in conjunction with the clinical presentation of a patient to help with quantifying infection severity and measuring treatment response. We report the case of a patient who presented with severe pneumonias but had a suboptimal CRP response, later diagnosed as having an underlying immunodeficiency. This case exemplifies the need to consider immunodeficiency as an underlying pathophysiological cause in patients presenting with complicated and severe infections.

Cardiorespiratory Fitness, Inflammation, and the Incident Risk of Pneumonia

INTRODUCTION

Both inflammation and cardiorespiratory fitness (CRF) are associated with the risk of respiratory infections. To clarify the hypothesis that CRF attenuates the incident risk of pneumonia due to inflammation, we conducted a prospective study examining the independent and joint associations of inflammation and CRF on the risk of pneumonia in a population sample of 2041 middle-aged men.

METHODS

Cardiorespiratory fitness was directly measured as peak oxygen uptake (V˙o2peak) during progressive exercise testing to volitional fatigue, and categorized into tertiles. Inflammation was defined by high-sensitivity C-reactive protein (hsCRP). Pneumonia cases were identified by internal medicine physicians using the International Classification of Diseases codes in clinical practice.

RESULTS

During a median follow-up of 27 yr, 432 pneumonia cases were recorded. High hsCRP and CRF were associated with a higher risk (HR = 1.38; 95% CI, 1.02-1.88) and a lower risk of pneumonia (HR = 0.55; CI, 0.39-0.76) after adjusting for potential confounders, respectively. Compared with normal hsCRP-Fit, moderate to high hsCRP-Unfit had an increased risk of pneumonia (HR = 1.63; CI, 1.21-2.20), but moderate to high hsCRP-Fit was not associated with an increased risk of pneumonia (HR = 1.25; CI, 0.93-1.68).

CONCLUSIONS

High CRF attenuates the increased risk of pneumonia due to inflammation. These findings have potential implications for the prevention of respiratory infection characterized by systemic inflammation, such as coronavirus disease-2019 (COVID-19).

Uterine endometrial cytology, biopsy, bacteriology, and serum C-reactive protein in clinically healthy diestrus bitches

The aim of this work was to assess the agreement between endometrial cytology and uterine biopsy for the diagnosis of endometritis (END), the bacterial populations isolated from the vagina and uterus of bitches having END, and the measurement of C- reactive protein as a diagnostic tool for diagnosis of END in clinically healthy bitches. Fifty privately-owned intact, clinically healthy bitches, in diestrus, without a history of progestin administration, aged between 8 months and 6 years old and weighing between 5 and 28 kg were used in this study. Bitches were included in a program for breeding control at a municipal pet public shelter. Before ovariohysterectomy (OVX) samples for vaginal cytology and bacteriology, and blood samples were taken. After OVX endometrial cytology, bacteriological samples and biopsy were collected. Histologic examination was performed to confirm the uterine condition. Blood samples were centrifuged and stored at -20 °C until progesterone (P₄) and C-reactive protein was measured. Samples for bacteriological culture were collected, and swabs were placed into Stuart's transport medium and transported to the laboratory. On histopathologic examination, the most common observation was END (27/50), followed by normal endometrium (NE; 18/50), cystic endometrial hyperplasia (CEH; 2/50), atrophy (2/50) and fibrosis with degeneration of the endometrial glands (1/50). Low degree of agreement was observed between results obtained by endometrial cytology samples and results obtained by biopsy in endometrial diagnosis (Kappa Coefficient: -0.19). In vaginal samples, β-hemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Proteus spp., Corynebacterium spp., and Klebsiella pneumoniae were the bacteria most often found. In uterine samples, only four samples from END showed bacterial grow. C-reactive protein frequency was higher in END (6/23, 23%) vs NE (0/16, 0%; Van der Waerden P-value = 0,0302). Our results support the hypothesis that END is a frequent finding in uterine biopsy and could be associated with subfertility and infertility in the bitch. A low degree of agreement was observed between the diagnostic results from the uterine biopsy and endometrial cytology. Bacteriology would not be recommended as a diagnostic tool because no bacteria highly associated with uterine diseases were isolated from bitches with END. Finally, the usefulness of C-reactive protein concentration as a marker for END in bitches could not be conclusively demonstrated.

Urine Dipstick of Sputum for the Rapid Diagnosis of Community Acquired Pneumonia

INTRODUCTION

Community acquired pneumonia (CAP) is responsible for an important part of treatment costs across the world. Even though posterior-anterior lung radiography (PALG) and direct sputum smear microscopy are required or routine diagnoses. The purpose of this study is to determine the diagnostic value of the bedside urine strip tests in CAP.

METHODS

Patients who attended the emergency department (ED) between from February 2016 to September 2016 with expectoration complaints and suspicion of pneumonia. The sensitivity, specificity, and accuracy rate of the urine strip tests, direct sputum smear microscopy, and PALG were calculated and analyzed using SPSS 15.0.

RESULTS

During the study period, 100 patients with pneumonia suspicion were evaluated in the ED. The sample was divided into two groups: negative and positive diagnosis of CAP. The leukocytes detecting by urine strip tests are statistical differences between the two groups (p: 0.003). The results show that the sensitivity, specificity, and accuracy rate of leukocytes detected in sputum with urine strip tests in the pneumonia diagnosis were 83.3%, 44.2% and 63% respectively.

CONCLUSION

According to the study, it is believed that the method of determination of leukocytes with urine strip tests in sputum combined with more detailed results. They can become part of CAP diagnosis methods.

Relevant analyses of pathogenic bacteria and inflammatory factors in neonatal purulent meningitis

Pathogenic bacteria and inflammatory factors in neonatal purulent meningitis (PM) were investigated to explore the diagnostic value of inflammatory factors in PM, to clarify the etiology, and to provide evidence for rational clinical treatment. Seventy-four neonates who were diagnosed with PM and were bacteriogically positive in Daqing Longnan Hospital from January 2012 to December 2015 were retrospectively analyzed and used as observation group. Another 74 neonates simultaneously hospitalized with non-PM factors were selected as control group. The levels of C-reactive protein (CRP) and β 2 microglobulin (β2MG) in cerebrospinal fluid in pediatric patients were measured, and the separation culture and identification of pathogenic bacteria were carried out at the same time. The results showed that i) neonatal PM often lacked specific clinical manifestations; ii) high risk factors of neonatal PM included gestational age, body weight <2,500 g, neonatal asphyxia, premature rupture of membranes, and umbilical or pulmonary infection; iii) the levels of CRP and β2MG in the cerebrospinal fluid in the neonatal PM group were significantly higher than those in the control group (P<0.05), and the neonatal PM group had obviously decreased levels of CRP and β2MG in the cerebrospinal fluid after treatment compared with those before treatment (P<0.05); iv) the positive rate of Gram-negative bacilli (G-bacilli) showed an increasing trend year by year in the past 4 years. Seventy-four strains of bacteria were isolated from the cerebrospinal fluid in neonatal PM group, including 45 strains of Gram-positive cocci (G+cocci, accounting for 60.81%) and 29 strains of G-bacilli (accounting for 39.19%). Among them, the top three were Escherichia coli, coagulase-negative staphylococci (CNS) and Streptococcus. These findings indicated that for suspected PM pediatric patients with high risk factors, the inflammatory factors in cerebrospinal fluid and the etiology should be investigated via lumbar puncture as early as possible to confirm the diagnosis. Pathogenic bacteria of meningitis mainly are Escherichia coli, CNS and Streptococcus, and the characteristics of pathogenic bacteria should be considered during experiential medication. The incidence rate of PM due to Streptococcus has an upward tendency and great damage, needing to arouse high attention in clinic.

ARDS in Fulminant Ornithosis and Treatment with Extracorporeal Lung Assist

We report a 47-year-old male patient with fulminant ornithosis who developed severe respiratory failure leading to acute respiratory distress syndrome (ARDS) complicated by gastrointestinal, neurological and renal symptoms. ARDS was successfully treated by extracorporeal lung assist. As leukocytosis is typically absent in ornithosis, C-reactive protein, interleukin 6 and procalcitonin were used as infection parameters in order to monitor clinical development. The English-language literature on severe cases of ornithosis requiring respiratory support over the past 30 years is reviewed.

Variation in the levels of IL-6 in pediatric patients with severe bacterial infectious diseases and correlation analysis between the levels of IL-6 and procalcitonin

The objective of the present study was to investigate variations in the levels of interleukin (IL)-6, procalcitonin (PCT), and C-reactive protein (CRP) in children with severe bacterial infectious diseases and to analyze the correlation between the levels of IL-6 and PCT to determine the value of combined diagnosis with IL-6 and PCT. We analyzed 126 patients admitted to Xuzhou Children's Hospital for treatment, who were divided into severe bacterial infection (observation group, n=65) and non-bacterial infection groups (control group, n=61). The levels of IL-6, PCT, and CRP were measured and compared between the two groups. Data from both groups were statistically analyzed. The levels of IL-6, PCT, and CRT in the observation group were significantly higher than those in the control group (P<0.01); in the observation group, the levels of IL-6 and PCT on the 5th and 10th day after treatment were significantly lower than those before treatment (P<0.01); PCT showed better value for diagnosing severe bacterial infections compared with IL-6 and CRP; there was a positive correlation between the levels of IL-6 and PCT in the observation group; and the sensitivity and specificity of combined diagnosis with IL-6 and PCT for severe bacterial infection was 93.84% and 96.72%, respectively, which were significantly higher than those for diagnosis with only IL-6 (P<0.01). In conclusion, IL-6 combined with PCT can serve as an indicator with high sensitivity for detection of severe bacterial infections in children, which is of great significance for the differential diagnosis of severe bacterial infections in the early stage.

A novel biochemical marker for community-acquired pneumonia: Ischemia-modified albumin

INTRODUCTION

Community-acquired pneumonia (CAP) is a frequent cause of hospitalization and a leading cause of mortality worldwide. Early diagnosis and the initiation of appropriate antibiotic therapy are essential to reduce pneumonia-related morbidity and mortality. CRP is a well-established biomarker in many clinical settings, but has been traditionally considered not specific enough to be a useful guide in the diagnostic process of pneumonia. There is still a need for more specific and practical markers in CAP for diagnosis. The aim of this study was to investigate the diagnostic value of ischemia-modified albumin (IMA) levels in the diagnosis of CAP in the Emergency Department.

METHODS

The study included 81 patients admitted with CAP and 81 control patients. Initial hour levels of IMA and CRP were measured. The IMA mean levels were compared between the study and control group. Correlation analyses were performed to investigate the association of serum IMA levels with CRP.

RESULTS

Mean levels of IMA were 0.532±0.117IU/ml in the study group and 0.345±0.082IU/ml in the control group. IMA levels were significantly higher in the study group compared to the control group. The IMA level of 0.442IU/ml had sensitivity of 75.3% and specificity of 91.3% and was positively correlated with CRP levels (r=0.506; p<0.05).

CONCLUSION

Blood IMA levels significantly increase in adult patients presenting with CAP. IMA may be considered as a novel biomarker in the diagnosis of CAP.

Plasma Monocyte Chemoattractant Protein-1 Level as a Predictor of the Severity of Community-Acquired Pneumonia

Monocyte chemoattractant protein (MCP)-1 increases in the serum of immunocompetent patients with community-acquired pneumonia (CAP). However, the correlation between the circulating level of MCP-1 and severity of CAP remains unclear. This study investigated differential changes in the plasma MCP-1 levels of patients with CAP before and after an antibiotic treatment and further analyzes the association between the CAP severity and MCP-1 levels. We measured the plasma MCP-1 levels of 137 patients with CAP and 74 healthy controls by using a commercial enzyme-linked immunosorbent assay. Upon initial hospitalization, Acute Physiology and Chronic Health Evaluation II (APACHE II); confusion, urea level, respiratory rate, blood pressure, and age of >64 years (CURB-65); and pneumonia severity index (PSI) scores were determined for assessing the CAP severity in these patients. The antibiotic treatment reduced the number of white blood cells (WBCs) and neutrophils as well as the level of C-reactive protein (CRP) and MCP-1. The plasma MCP-1 level, but not the CRP level or WBC count, correlated with the CAP severity according to the PSI (r = 0.509, p < 0.001), CURB-65 (r = 0.468, p < 0.001), and APACHE II (r = 0.360, p < 0.001) scores. We concluded that MCP-1 levels act in the development of CAP and are involved in the severity of CAP.

Evaluation of a combined MxA and CRP point-of-care immunoassay to identify viral and/or bacterial immune response in patients with acute febrile respiratory infection

Background

Challenges in the clinical differentiation of viral and/or bacterial respiratory infection lead to the misappropriation of antibiotics and increased healthcare costs. A tool to facilitate rapid and accurate point-of-care (POC) differentiation is needed.

Methods and findings

A prospective, single center, blinded, observational clinical trial was conducted at Beth Israel Deaconess Medical Center from December 2012 to August 2013 to determine the accuracy of a POC immunoassay to identify a clinically significant immune response to viral and/or bacterial infection. Sixty patients with acute febrile respiratory infection (19 pharyngitis and 41 lower respiratory tract infection [LRTI]) were enrolled. Participants provided fingerstick blood for immunoassay testing (myxovirus A [MxA] and c-reactive protein [CRP]) and four oropharyngeal samples for viral PCR and routine bacterial cell culture. A venous blood sample was collected. An ELISA was used to measure CRP and MxA. Paired serological testing was used to confirm atypical bacteria. A urine sample was provided for Streptococcus and Legionella antigen testing. Patients with suspected LRTI had sputum and blood cultures, chest X-ray, and WBC count measured. Viral infection was confirmed if oropharyngeal PCR was positive for viral pathogens. Bacterial infection was confirmed in positive throat or sputum cultures. Elevated immunoglobulin M antibodies or twofold increase in IgG antibodies between acute and convalescent phase indicated atypical bacteria. Positive Streptococcus or Legionella urine antigen assays also confirmed bacterial infection. The immunoassay correctly categorized subjects as 92% (22/24) negative, 80% (16/20) with bacterial infection, and 70% (7/10) with viral infection.

Conclusions

The interplay between an MxA value and a semi-quantitative CRP value can aid in the differentiation of infectious etiology. In isolation, neither MxA nor CRP alone is sensitive or specific. However, the pattern of results in a rapid immunoassay provides a sensitive and specific method to differentiate acute febrile respiratory infections. This diagnostic information may help reduce antibiotic misuse and resistance and lower healthcare costs.

Biomarkers for community-acquired pneumonia in the emergency department

Community-acquired pneumonia is one of the most common reasons for emergency department (ED) visits in children and adults. Despite its prevalence, there are many challenges to proper diagnosis and management of pneumonia. There is no accurate and timely etiologic gold standard to differentiate bacterial from viral disease, and there are limitations with precise risk stratification of patients to ensure appropriate site-of-care decisions. Clinical factors obtained by history and physical examination have limited the ability to diagnose pneumonia etiology and severity. Biomarkers offer information about the host response to infection and pathogen activity within the host that can serve to augment clinical features in decision-making. As science and technology progress, novel biomarkers offer great potential in aiding critical decisions for patients with pneumonia. This review summarizes existing knowledge about biomarkers of host response and pathogen activity, in addition to briefly reviewing emerging biomarkers using novel technologies.

Elevated plasma stromal-cell-derived factor-1 protein levels correlate with severity in patients with community-acquired pneumonia

BACKGROUND

The aim of this study was to investigate differential changes in plasma levels of stromal-cell-derived factor-1 (SDF-1) before and after antibiotic treatment in patients with community-acquired pneumonia (CAP) and observe the association between the severity of CAP and the plasma SDF-1 level.

METHODS

We gathered blood specimens from 61 adult CAP patients before and after antibiotic treatment and from 60 healthy controls to measure the plasma concentrations of SDF-1 by using an enzyme-linked immunosorbent assay.

RESULTS

The plasma SDF-1 concentration was elevated significantly in patients with CAP before receiving treatment compared with the controls and decreased significantly after the patients received treatment. Leukocyte (WBC) and neutrophil counts and C-reactive protein (CRP) levels decreased significantly after antibiotic treatment. Moreover, differences in the plasma concentration of SDF-1 were significantly correlated with PSI, CURB-65, and APACHE II scores (r = 0.389, P = 0.002, and n = 61; r = 0.449, P < 0.001, and n = 61; and r = 0.363, P = 0.004, and n = 61, resp.).

CONCLUSIONS

An elevated plasma SDF-1 concentration can be used as a biological marker for the early diagnosis of CAP and for the early detection of its severity.

Usefulness of the endotoxin activity assay to evaluate the degree of lung injury

PURPOSE

It has been reported that the Pulse Contour Cardiac Output (PiCCO) is very useful mainly in the field of intensive care and treatment to grasp the pathophysiological conditions of pulmonary edema because of its capability of obtaining data such as Pulmonary Vascular Permeability Index (PVPI) and Extra Vascular Lung Water (EVLW). Furthermore, a high degree of usability of various markers has been reported for better understanding of the pathological conditions in cases with septicemia.

MATERIALS AND METHODS

The correlation between the cardiorespiratory status based upon the PiCCO monitor (EVLW and PVPI) and inflammatory markers including C reactive protein, procalcitonin (PC), and Endotoxin Activity Assay (EAA) were evaluated in 11 severe cases that required treatment with a respirator in an intensive care unit.

RESULTS

The EAA values were significantly higher in patients with abnormal EVLW at 0.46±0.20 compared to the normal EVLW group at 0.21±0.19 (p=0.0064). In a similar fashion, patients with abnormal PVPI values tended to have higher PC levels at 18.9±21.8 compared to normal PVPI cases at 2.4±2.2 (p=0.0676). On the other hand, PVPI was significantly higher in the abnormal EAA group at 3.55±0.48 in comparison with the normal EAA group at 1.99±0.68 (p=0.0029). The abnormal EAA group tended to have higher PVPI values than the normal EAA group.

CONCLUSION

The EAA is a measurement method designed to estimate the activity of endotoxins in the whole blood. Our results suggest that the EAA value, which had the greatest correlation with lung disorders diagnosed by the PiCCO monitoring, reflects inflammatory reactions predominantly in the lungs.

Diagnostic value and prognostic significance of pleural C-reactive protein in lung cancer patients with malignant pleural effusions

PURPOSE

C-reactive protein (CRP) has been implicated in various inflammatory and advanced malignant states. Increased serum CRP (s-CRP) levels have been shown to be associated with independent prognostic factors for survival in patients with advanced lung cancer. However, only few studies have focused on the role of CRP in pleural effusions. This study aimed to evaluate the diagnostic and prognostic value of pleural CRP (p-CRP) in lung cancer patients with malignant pleural effusion (MPE).

MATERIALS AND METHODS

Pleural effusion (PE) samples were collected from patients with MPE (68 lung cancers; 12 extrathoracic tumors), and from 68 patients with various benign conditions (31 with pneumonia; 37 with tuberculosis). Concentrations of p- and s-CRP were measured by enzyme-linked immunosorbent assay. CRP level in pleural fluid and its association with survival were examined.

RESULTS

p-CRP levels correlated with s-CRP levels (r=0.82, p<0.0001). For the differential diagnosis of MPE and benign PE, the area under the receiver operating characteristic curve was greater for p-CRP (0.86) than for s-CRP (0.77). High p-CRP expression significantly correlated with shorter overall survival (p=0.006). P-CRP was independent prognostic factor significantly associated with overall survival on multivariated analysis (p=0.0001). The relative risk of death for lung cancer patients with high p-CRP levels was 3.909 (95% confidence interval, 2.000-7.639).

CONCLUSION

P-CRP is superior to s-CRP in determining pleural fluid etiology. Quantitative measurement of p-CRP might be a useful complementary diagnostic and prognostic test for lung cancer patients with MPE.

The role of biomarkers in low respiratory tract infections

Low respiratory tract infections (LRTI) represent the leading infectious cause of death worldwide and account for substantial use of healthcare resources. Physicians must adopt practices focused on improving outcomes and serum biomarker can help them in the management of patients with LRTI. Several studies have been carried out or are currently ongoing to evaluate the role of various biomarkers for the differential diagnosis, definition of prognosis, treatment and duration of antibiotic therapy in respiratory infections. The objective of this position paper of the Italian Society of Respiratory Diseases (SIMER) is to provide evidence-based recommendations for the use of biomarkers in routine clinical practice in the management of adult patients with LRTI. These guidelines capture the use of biomarkers both outside and inside the hospital, focused on community-acquired pneumonia, acute exacerbations of chronic obstructive pulmonary disease, hospital-acquired and ventilator-acquired pneumonia.

A multi-country qualitative study of clinicians' and patients' views on point of care tests for lower respiratory tract infection

BACKGROUND

Point of care tests (POCTs) are being promoted to better target antibiotic prescribing with the aim of improving outcomes and containing antibiotic resistance.

OBJECTIVE

We aimed to explore clinician and patient views about POCTs to assist with the diagnosis and management of lower respiratory tract infection (LRTI) in primary care.

METHODS

Multi-country European qualitative interview study with 80 primary care clinicians and 121 adult patients in nine primary care networks who had recently consulted with symptoms of acute cough/LRTI. Transcripts were subjected to a five-stage analytic framework approach (familiarization, developing a thematic framework from the interview questions and the themes emerging from the data, indexing, charting, and mapping to search for interpretations in the data), with local network facilitators commenting on preliminary reports.

RESULTS

Clinicians who did not routinely use POCTs for acute cough/LRTI felt that the tests' advantages included managing patient expectations for antibiotics. Perceived disadvantages included questionable test performance, problems interpreting results, a detraction from clinical reasoning, costs, time and patients not wanting, or demanding, the tests. Clinicians who routinely used POCTs echoed these disadvantages. Almost all patients would be happy to be managed with the addition of a POCT. Patients with experience of POCTs accepted it as part of routine care.

CONCLUSIONS

Acceptability of POCTs to clinicians is likely to be improved if tests perform well on accuracy, time to result, simplicity and cost. Including POCTs in the routine management of acute cough/LRTI is likely to be acceptable to most patients.

Bringing immunoglobulin knowledge up to date: how should we treat today?

Immunoglobulin (Ig) therapy is constantly evolving. Advances in the basic and clinical science of immunoglobulins have provided new perspectives in using polyclonal IgG to treat patients with primary immunodeficiencies. Recent meta-analyses of patient data and outcomes, optimization of IgG administration and better understanding of the IgG receptor variability and clinical effect are new concepts which practising immunologists can use in tailoring their approach to treating patients with primary immunodeficiencies. This manuscript presents the proceedings of a satellite symposium, held in conjunction with the European Society for Immunodeficiencies (ESID) 2010 meeting, to inform attendees about new scientific concepts in IgG therapy, with the goal of empowering expert level evaluation of what optimal IgG therapy is today.

C-reactive protein serum levels as an early predictor of outcome in patients with pandemic H1N1 influenza A virus infection

Background

Data for predicting which patients with pandemic influenza A (H1N1) infection are likely to run a complicated course are sparse. We retrospectively studied whether the admission serum C-reactive protein (CRP) levels can serve as a predictor of illness severity.

Methods

Included were all consecutive adult patients who presented to the emergency department (ED) between May-December, 2009 with a flu-like illness, a confirmed diagnosis of pandemic influenza A (H1N1) infection and a serum CRP level measured within 24 hours of presentation. Patients with a proven additional concurrent acute illness (e.g., bacteremia) were excluded. We used the ROC curve analysis, Kaplan-Meier curves and the Cox proportional hazard model to evaluate the predictive ability of CRP as a prognostic factor.

Results

Seventeen (9%) of the 191 enrolled patients were admitted to the intensive care unit (ICU), of whom eight (4%) required mechanical ventilation and three (2%) died. The median admission serum CRP levels were significantly higher among patients who required subsequent ICU care and mechanical ventilation than among patients who did not (123 mg/L and 112 mg/L vs. 40 mg/L, p < .001 and 43 mg/L, p = .017, respectively). A Cox proportional hazard model identified admission serum CRP levels and auscultatory findings over the lungs as independent prognostic factors for ICU admission. Admission serum CRP levels were the only independent prognostic factor for mechanical ventilation. Thirty days after presenting to the ED, none of the patients with admission serum CRP level <28 mg/L (lower tertile) required either ICU admission or mechanical ventilation. At the same time point, 19% of the patients with admission serum CRP level ≥70 mg/L (upper tertile) needed to be admitted to the ICU and 8% of the same upper tertile group required mechanical ventilation. The differences in the rates between the lower vs. upper tertile groups were significant (Log-Rank p < .001 for ICU and p < .024 for mechanical ventilation).

Conclusions

In our study group, serum CRP levels obtained in the early ED admission stage from patients presenting with pandemic H1N1 influenza A infection were found to serve as a useful gauge for predicting disease course and assisting in patient management.

Biomarkers: a definite plus in pneumonia

During the past few years, biomarkers have emerged as an indispensible tool in the diagnosis of pneumonia. To find an ideal diagnostic biomarker for pneumonia is not an easy task. Not only should it allow an early diagnosis of the condition, but it should also allow differential diagnosis from other noninfectious conditions. Ongoing research is being done in this field so as to put an array of biomarkers at the disposal of doctors to improve the diagnosis of pneumonia when patients present to them with cough or nonspecific symptoms which could easily be misinterpreted as symptoms of other conditions. Procalcitonin and soluble triggering receptor expressed on myeloid cells-1 have emerged as reliable diagnostic markers in pneumonia, and are better when compared to other markers, namely, C-reactive protein, leukocyte count, and proinflammatory cytokines. Many other biomarkers are being studied for their probable use in diagnosing pneumonia but have yet to prove their benefit.

C-reactive protein, severity of pneumonia and mortality in elderly, hospitalised patients with community-acquired pneumonia

BACKGROUND

increasingly, markers of systemic inflammation like C-reactive protein (CRP) levels and white blood count (WBC) are being used for assessing the prognosis of patients with community-acquired pneumonia (CAP). However, their predictive value has not been validated in populations of elderly patients.

OBJECTIVE

to evaluate the prognostic value of CRP and WBC in comparison with the CURB score and the pneumonia severity index (PSI) in elderly, hospitalised patients with CAP.

METHODS

the charts of all patients, aged 65 years and older, who were consecutively admitted to the Department of Geriatrics, Marienhospital Herne, Germany, for treatment of CAP between January 2001 and September 2005, were reviewed. CRP, WBC, CURB and PSI were analysed in relation to 30-day mortality.

RESULTS

in a total of 391 patients, median age 80 years, no association was found between CRP or WBC and mortality. In contrast, the CURB score and PSI were significantly associated with mortality and treatment in the intensive care unit (ICU).

CONCLUSION

in elderly, hospitalised patients with CAP, admission CRP and WBC are not predictors of the prognosis.

Can C-reactive protein, procalcitonin and mid-regional pro-atrial natriuretic peptide measurements guide choice of in-patient or out-patient care in acute pyelonephritis? Biomarkers In Sepsis (BIS) multicentre study

Whereas C-reactive protein (CRP), procalcitonin (PCT) and mid-regional pro-atrial natriuretic peptide (ANP) may be of use at the bedside in the management of adult patients with infectious disorders, their usefulness has not been established in the setting of acute pyelonephritis. To assess the effectiveness of CRP, PCT and ANP measurements in guiding emergency physicians' decisions whether to admit to hospital patients with acute pyelonephritis, we conducted a multicentre, prospective, observational study in 12 emergency departments in France; 582 consecutive patients were included. The reference standard for admission was defined by experts' advice combined with necessity of admission or death during the 28-day follow-up. Baseline CRP, PCT and ANP were measured and their accuracy in identifying the necessity of admission was analysed using area under curves (AUC) of receiver-operating characteristic (ROC) plots. According to the reference standard, 126 (22%) patients required admission. ANP (AUC 0.75, 95% CI 0.69-0.80) and PCT (AUC 0.75, 95% CI 0.71-0.80) more accurately predicted this than did CRP (AUC 0.69, 95% CI 0.64-0.74). The positive and negative likelihood ratios for each biomarker remained clinically irrelevant whatever the threshold. Our results did not support the use of these markers to help physicians in deciding about admission of patients experiencing acute pyelonephritis in daily practice.

C-reactive protein in diagnosis of community-acquired pneumonia in adult patients in primary care

The usefulness of non-specific inflammatory parameters for the diagnosis of community- acquired pneumonia (CAP) in primary care is not settled. The aim of this study was to assess the value of serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and white blood cell count (WBC) for this purpose. These inflammatory parameters, as well as the aetiological agents, were studied in 82 patients with radiologically confirmed CAP. CRP was elevated (>5 mg/l) in 76 patients, with a median value of 65 mg/l. 25 patients had a value of over 100 mg/l. In 32 patients the CRP levels were <50 mg/l and in 17 patients they were <20 mg/l. ESR varied from 5 to 100 mm/h, with a median value of 53 mm/h; in 21 patients the value was <30 mm/h. WBC varied from 4.4 to 21.4x10(9)/l, with a median value of 9.8x10(9)/l. No associations between the levels of the inflammatory parameters and the various aetiologies were found. It is concluded that the examined inflammatory parameters did not contribute notably in the routine diagnosis of CAP established by clinical measures.

C-reactive protein and other predictors of poor outcome in patients hospitalized with exacerbations of chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVE

CRP is elevated in patients with acute exacerbations of COPD (AECOPD), but there is little information on whether this biomarker can help to identify adverse short-term clinical outcomes.

METHODS

A 6-month prospective study of all patients with AECOPD requiring hospital admission. Clinical, laboratory (including plasma CRP levels at admission) and functional data were recorded. The outcome variable (the adverse outcome) consisted of: (i) death in hospital or within 15 days of discharge, (ii) transfer to the intensive care unit, or (iii) development of acute heart failure during hospitalization.

RESULTS

Data from 147 patients with a total of 160 admissions were recorded. During follow up, 38 (23.7%) adverse outcomes were observed, including 13 (8.8%) and 8 (5.4%) patients who died during hospitalization or within 15 days of discharge, respectively. CRP at a level of 50 mg/L was related to an adverse outcome (OR 4.9, 95% CI: 1.92-12.6, P < 0.01), although by itself it was neither sensitive nor specific (area under the receiver operating characteristic curve (AUC) 0.69, 95% CI: 0.60-0.77). However, a risk score derived from the combination of CRP with other variables, such as 'current smoker', 'at least two comorbidities' and 'confusion,' at admission showed good predictive ability to identify an adverse outcome (AUC of 0.80, 95% CI: 0.72-0.88).

CONCLUSIONS

Plasma CRP in combination with other variables obtained at admission may assist identification of high-risk patients with AECOPD.

Serum markers in community-acquired pneumonia and ventilator-associated pneumonia

PURPOSE OF REVIEW

This article reviews recent data on the usefulness of serum markers in community-acquired pneumonia and ventilator-associated pneumonia. The focus is on clinical studies, with an emphasis on adult critically ill patients.

RECENT FINDINGS

Serum markers have demonstrated potential value in early prediction and diagnosis of pneumonia, in monitoring the clinical course and in guiding antibiotic therapy. C-reactive protein appears to perform better in diagnosing infection, because several studies have shown that procalcitonin may remain undetectable in some patients, specifically those with pneumonia. Procalcitonin exhibited a better correlation with clinical severity, however. Furthermore, one report demonstrated the efficacy and safety of procalcitonin-guided antibiotic therapy in community-acquired pneumonia.

SUMMARY

Serum markers should only be used as a complementary tool to support the current clinical approach. Use of serum markers, in particular procalcitonin and C-reactive protein, represents a promising strategy in the clinical decision-making process in patients in whom pneumonia is suspected. Specifically, these markers can be used to guide culture sampling and empirical antibiotic prescription, and to monitor the clinical course, adjust the duration of antibiotic therapy and identify nonresponders, in whom an aggressive diagnostic and therapeutic approach may prevent further clinical deterioration.

C-reactive protein levels in patients with chronic obstructive pulmonary disease: role of infection

OBJECTIVE

To investigate the value of C-reactive protein (CRP) as a marker of chronic obstructive pulmonary disease (COPD) exacerbations or specifically bacterial exacerbations and to evaluate a correlation between raised CRP levels and other markers of inflammation in patients with an acute exacerbation (AECOPD).

SUBJECTS AND METHODS

The medical records of patients with AECOPD were retrospectively analyzed. They were categorized according to the nature of sputum as mucoid or purulent and to the findings on chest radiographs as with pneumonia (PCOPD) or without pneumonia. Stable COPD (SCOPD) patients and a group of asymptomatic nonsmokers were also included in the study.

RESULTS

All COPD patients (SCOPD: 30; AECOPD: 51; PCOPD: 32) and control subjects (30) were male. The mean CRP levels and WBC counts of the groups were PCOPD: 108.1 +/- 61.8 mg/l and 13.7 +/- 6.8 x 10(9)/l; AECOPD: 36.8 +/- 43.9 mg/l and 11.4 +/- 4.8 x 10(9)/l; SCOPD: 3.9 +/- 1.4 mg/l and 7.9 +/- 1.9 x 10(9)/l; control: 2.1 +/- 0.9 mg/l and 7.7 +/- 1.1 x 10(9)/l. The mean CRP level of AECOPD was statistically different from those of PCOPD and SCOPD (p = 0.0001, p = 0.002, respectively). The sensitivity and specificity of CRP to determine an acute exacerbation were 72.5 and 100%, respectively. Among the patients with AECOPD, 25 had purulent sputum and a mean CRP level of 46.4 +/- 48.6 mg/l, which is significantly higher than the CRP level (28.0 +/- 44.5 mg/l) of the 18 patients with mucoid expectoration (p = 0.015). Among the mucoid-expectorating subgroup, the patients with leukocytosis had significantly higher CRP levels than the patients without leukocytosis (p = 0.034).

CONCLUSION

A high serum CRP value may indicate an infectious exacerbation in COPD patients and it correlates with sputum purulence and increased serum WBC counts.

Predictive value of serial measurements of sTREM-1 in the treatment response of patients with community-acquired pneumonia

BACKGROUND/PURPOSE

To evaluate the roles of plasma sTREM-1 (soluble triggering receptor expressed on myeloid cells-1) and C-reactive protein (CRP) in predicting treatment response in patients with community-acquired pneumonia (CAP).

METHODS

Patients with CAP were enrolled prospectively at a medical center in central Taiwan from September 1, 2004 to July 31, 2005. They were treated according to the guidelines proposed by the American Thoracic Society. Patients were noted as nonresponsive to initial treatment if they had one of the following: persistent fever for more than 3 days, progression on chest radiograph, switching to other antibiotics, or need of mechanical ventilation and/or chest tube drainage.

RESULTS

Fifty-eight patients (43 males/15 females; mean age, 67 +/- 21 years) with CAP were enrolled. Twelve (12/58, 21%) were nonresponsive. In the response group, CRP was reduced up to 58% from day 1 to day 3 (from 18.8 to 7.8 mg/dL), whereas sTREM-1 was reduced by only 15% (from 32.8 to 28.1 pg/mL). In the nonresponse group, CRP still declined 20% (from 22.2 to 17.7 mg/dL), whereas sTREM-1 was persistently high (from 61.7 to 63.7 pg/mL). Using multivariate logistic regression analysis, both CRP (p = 0.006) and sTREM-1 (p = 0.046) on day 3 predicted treatment response significantly, but CRP on day 3 had stronger statistic power.

CONCLUSION

Both CRP and sTREM-1 on day 3 could be useful in predicting nonresponsive CAP patients. Differential trends between sTREM-1 and CRP in nonresponsive CAP suggest that sTREM-1 could be an adjuvant biomarker to CRP in predicting CAP patients without response to empiric treatment.

Middle-aged and Elderly Outpatients Show Lower Body Temperature Responses than the Young, Even with the Same C-reactive Protein Levels

The variation of body temperature response and C-reactive protein (CRP) levels with age was investigated. A cross-sectional study on new outpatients between January 2004 and June 2005 was carried out. Body temperature and serum CRP levels were examined for screening purposes in 1081 patients. Mean axillary body temperature was maintained at around 36.7°C in early adulthood, and gradually declined in middle age. Middle-aged and elderly outpatients tended to show a lower body temperature response than the young, even with the same CRP levels. The critical age (boundary age) was assumed to be when the relationship between body temperature response and CRP level changed. This study suggests that the boundary age is about 40 years old.

Acute phase markers for the differentiation of infectious and malignant pleural effusions

Acute-phase markers, such as C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha), have been studied in inflammatory and malignant disorders. We examined the diagnostic value of these markers for the differentiation among parapneumonic, tuberculous and malignant effusions. We studied 124 patients with pleural effusions, classified as exudates [total (n=97), parapneumonic (n=15), tuberculous (n=25), malignant (n=57)] and transudates due to congestive heart failure (n=27). CRP, IL-6 and TNF-alpha were measured in pleural fluid and serum. Pleural fluid CRP was higher in parapneumonic compared to tuberculous and malignant effusions, providing 100% sensitivity for a cut-off point of 5.3mg/dL. IL-6 was higher in both parapneumonic and tuberculous compared to malignant effusions. TNF-alpha was higher in tuberculous compared to malignant effusions, providing 96.0% sensitivity, and 93.0% specificity for a cut-off point of 88.1 pg/mL. Pleural fluid CRP levels were lower than serum in all groups, probably reflecting systemic inflammation, whereas IL-6 and TNF-alpha were higher in pleural fluid indicating local production. Our data suggest that these markers may provide useful information for the differentiation of infectious and malignant effusions in clinical practice. However, further studies are needed for the validation of these findings in usual clinical circumstances.

[Critical evaluation and predictive value of clinical presentation in out-patients with acute community-acquired pneumonia]

Diagnostic probability of community-acquired pneumonia (CAP) depends on data related to age and clinical and radiological findings. The critical evaluation of data in the literature leads to the following conclusions: 1) the prevalence of CAP in a given population with acute respiratory disease is 5% in outpatients and 10% in an emergency care unit. This could be as low as 2% in young people and even higher than 40% in hospitalized elderly patients; 2) the collection of clinical data is linked to the way the patient is examined and to the expertise of the clinician. The absolute lack of "vital signs" has a good negative predictive value in CAP; presence of unilateral crackles has a good positive predictive value; 3) there is a wide range of X-ray abnormalities: localized alveolar opacities; interstitial opacities, limited of diffused. The greatest radiological difficulties are encountered in old people with disorders including chronic respiratory or cardiac opacities and as a consequence of the high prevalence of bronchopneumonia episodes at this age; 4) among patients with lower respiratory tract (LRT) infections, the blood levels of leukocytes, CRP and procalcitonine are higher in CAP patients, mainly when their disease has a bacterial origin. Since you have not a threshold value reliably demonstrated in large populations with LRT infections or acute respiratory disease, presence or absence of these parameters could only be taken as a slight hint for a CAP diagnosis.

[CRP in the management of bacterial infections in emergency]

OBJECTIVES

To assess the interest of measuring CRP in emergency for diagnosing bacterial infections and making decisions about antibiotics and to compare its practical usefulness with clinicians' conclusions.

METHODS

Systematic CRP measurements in 80 consecutive patients admitted to emergency ward with possible bacterial infection.

RESULTS

were not transmitted to the physician in charge. Patients' files were analyzed retrospectively in two phases. In phase 1, two senior physicians assessed the diagnosis and need for antibiotics on the basis of the admission (emergency unit) files. In phase 2, a panel of experts examined the complete files (including discharge notes) to determine the likelihood of infection (obvious or probable, unlikely or excluded) and appropriateness of emergency antibiotics. Their recommendations were used as the standard, against which the usefulness of the laboratory indicators (including CRP) and decisions of the emergency physicians were assessed. ROC curves were used to determine threshold values for CRP and body temperature. We then calculated the sensitivity, positive predictive value and negative predictive value of these cutoffs and compared them with those for the phase 1 clinician recommendations.

RESULTS

The study included 76 patients (mean age: 74 years): 28 presented obvious or possible infections and 21 required emergency antibiotic therapy. Mean leukocyte values did not differ between groups. For diagnosis, the threshold value of CRP was 85 mg/L and of body temperature 37.8 degrees C; for prescribing antibiotics, the values were 130 mg/L and 38 degrees C, respectively. The sensitivity, specificity, negative and positive predictive values of CRP were, respectively, 79, 81, 76, and 83% for diagnosis of bacterial infection and 71, 71, 48 and 87% for prescription of an emergency antibiotic. These values were lower than those of clinician's conclusions.

CONCLUSION

Because of the variability in the thresholds used in its interpretation, the lack of specificity, and its poor predictive value for treatment decisions, CRP is of little interest in the diagnosis and treatment of patients with bacterial infections in intensive care. The cost generated by this examination is therefore not justified.

Diagnostic value of C reactive protein in infections of the lower respiratory tract: systematic review

OBJECTIVES

To evaluate the diagnostic accuracy of C reactive protein in detecting radiologically proved pneumonia and to evaluate how well it can discriminate between bacterial and viral infections of the lower respiratory tract.

DATA SOURCES

Medline and Embase (January 1966 to April 2004), with reference checking.

STUDY SELECTION

We included articles comparing C reactive protein with a chest radiograph or with microbiological work-up as a reference test. Two authors independently assessed methodological items.

RESULTS

None of the studies met all validity criteria. Six studies used an infiltrate on chest radiograph as reference test. Sensitivities ranged from 10% to 98%, specificities from 44% to 99%. For adults, the relation of C reactive protein with an infiltrate (in a subgroup analysis of five studies) showed an area under the curve of 0.80 (95% confidence interval 0.75 to 0.85). In 12 studies, the relation of C reactive protein with a bacterial aetiology of infection of the lower respiratory tract was studied. Sensitivities ranged from 8% to 99%, specificities from 27% to 95%. These data were epidemiologically and statistically heterogeneous, so overall outcomes could not be calculated.

CONCLUSION

Testing for C reactive protein is neither sufficiently sensitive to rule out nor sufficiently specific to rule in an infiltrate on chest radiograph and bacterial aetiology of lower respiratory tract infection. The methodological quality of the diagnostic studies is generally poor. The evidence not consistently and sufficiently supports a wide introduction of C reactive protein as a rapid test to guide antibiotics prescription.

Management of acute bronchitis in healthy adults

Acute respiratory infections (ARIs) are the most common infections in humans, accounting for half of all acute conditions each year in the United States. Acute bronchitis episodes represent a significant portion of these illnesses. This article focuses on acute bronchitis in otherwise healthy individuals.

Performance of a bedside C-reactive protein test in the diagnosis of community-acquired pneumonia in adults with acute cough

PURPOSE

To evaluate the performance of a rapid, bedside whole blood C-reactive protein test as a diagnostic test for pneumonia in adults.

METHODS

We enrolled consecutive adults who presented with acute cough (duration < or =3 weeks). A fingerstick blood specimen for C-reactive protein level was obtained. Patients also provided information about demographic characteristics and symptoms. Physical examination findings, diagnoses, and treatments were abstracted from the medical record; illness duration and subsequent office visits were determined with follow-up telephone calls. A clinical prediction rule for pneumonia was calculated for each patient and compared with C-reactive protein levels.

RESULTS

Twenty (12%) of the 168 patients in the study had radiographic evidence of pneumonia. Median C-reactive protein levels were significantly higher for patients with pneumonia than in the remaining patients (60 mg/L vs. 9 mg/L, P <0.0001). The area under the receiver operating characteristic (ROC) curve for C-reactive protein level as a predictor of pneumonia was 0.83. C-reactive protein level and the clinical prediction rule were independently associated with pneumonia, yielding a combined area under the ROC curve of 0.93. C-reactive protein level was not associated with hospitalization or resolution of symptoms.

CONCLUSION

C-reactive protein levels could be a valuable addition to clinical prediction rules for pneumonia. A C-reactive protein level > or =100 mg/L might be a useful indication for chest radiography or empiric antibiotic therapy when the diagnosis of pneumonia is in doubt.

Contribution of C-Reactive Protein to the Diagnosis and Assessment of Severity of Community-Acquired Pneumonia

STUDY OBJECTIVE

To assess the usefulness of serum C-reactive protein (CRP) in the diagnosis and treatment approach of patients with community-acquired pneumonia (CAP).

DESIGN

Population-based case-control study.

SETTING

A mixed residential-industrial urban area of 74,368 adult inhabitants in the Maresme region (Barcelona, Spain).

PATIENTS

From December 1993 to November 1995, all subjects who were > 14 years of age, were living in the area, and had received a diagnosis of CAP, which had been confirmed by chest radiographs and compatible clinical outcome, were registered. Patients from residential care facilities were excluded. Serum samples were assayed for CRP in the acute phase of the disease. Data from 201 patients with CAP were compared with 84 healthy control subjects matched by age, sex, and municipality, as well as with 25 patients with initially suspected pneumonia that was not confirmed at follow-up. Median CRP levels were 110.7, 1.9, and 31.9 mg/L, respectively. The thresholds of the test for discriminating among these three groups of subjects were 11.0 and 33.15 mg/L.

RESULTS

Eighty-nine patients (44.8%) had an identifiable etiology. The most common pathogens were Streptococcus pneumoniae, viruses, and Chlamydia pneumoniae, followed by Mycoplasma pneumoniae, Legionella pneumophila, and Coxiella burnetii. There were statistically significant differences in the median CRP levels in pneumococcal (166.0 mg/L) and L pneumophila (178.0 mg/L) etiologies compared to other causative pathogens. Lower levels of CRP were found in pneumonia caused by viruses and C burnetii as well as in negative microbiological findings. The median CRP levels in hospitalized patients were significantly higher than in outpatients (132.0 vs 76.9 mg/L, respectively; p < 0.001). Considering a cut point of 106 mg/L in men and 110 mg/L in women for deciding about the appropriateness of inpatient care, CRP levels showed a sensitivity of 80.51% and a specificity of 80.72%.

CONCLUSIONS

Serum CRP level is a useful marker for establishing the diagnosis of CAP in adult patients with lower respiratory tract infections. High CRP values are especially high in patients with pneumonias caused by S pneumoniae or L pneumophila. Moreover, high CRP values are suggestive of severity, which may be of value in deciding about the appropriateness of inpatient care.

Evaluation of an algorithm for switching from IV to PO therapy in clinical practice in patients with community-acquired pneumonia

BACKGROUND

In patients with community-acquired pneumonia (CAP), switching from IV to PO antibiotics offers advantages over IV therapy alone, including improved cost-effectiveness through reductions in the length of hospital stay and treatment costs.

OBJECTIVE

The aim of this study was to determine whether a method for switching therapy in clinical practice could be used in patients with CAP and whether differences were found in the duration of IV treatment and length of hospital stay between the 5 risk classes of the Pneumonia Severity Index (PSI) after the therapy switch.

METHODS

This was a prospective, observational study of patients aged >/=18 years presenting with CAP at our teaching hospital between December 1998 and November 2000. Microbiological and serological tests were performed, and signs and symptoms of CAP, C-reactive protein levels, and white blood cell counts were assessed throughout treatment and at the 1-month follow-up. Patients were stratified by PSI risk class. When the patient's temperature had been normalized for 72 hours and respiratory symptoms (dyspnea, coughing, and thoracal pain) had improved, patients were switched from IV to PO therapy (same drug).

RESULTS

The study included 180 patients with CAP Clinical cure was seen in 174 (97%) patients. No significant difference between the 5 risk classes was found in duration of therapy. Patients in risk class V remained hospitalized for a significantly longer period than patients in risk classes I through IV (P < 0.001). Furthermore, after patients were switched to PO antibiotics, the level of C-reactive protein decreased in patients in all risk classes and was normalized by follow-up.

CONCLUSIONS

In the population studied, use of specific criteria (ie, absence of fever for 72 hours and reduction in respiratory symptoms) allowed successful switch from IV to PO antibiotic therapy for the treatment of CAP Duration of therapy was not affected by PSI risk class, but those in risk class V were hospitalized longer than other risk classes.

Clinical management of immunocompetent hospitalized patients with community-acquired pneumonia

Background: Clinical practices and guidelines may differ regarding the management of inpatients with community-acquired pneumonia (CAP). Methods: The management of 152 consecutive CAP inpatients (70+/-17 years) admitted to a teaching hospital was analyzed retrospectively and compared with published data and an evidence-based guideline developed at our institution. Results: Of the patients studied, 64% had a high prognostic score index (PSI), 14% were admitted to the ICU, and 4.6% died. Initially, patients received either a one-drug (47%) or a two-drug (53%) antibiotic regimen. None of the 20 PSI parameters, and neither the PSI nor admission to the ICU, was associated with the initial antibiotic regimen. Agreement between current practice and our guideline was low (kappa=0.16). Following the recommendations would have led to a decrease of 51% in the initial two-drug regimen. The duration of i.v. antibiotherapy was higher in patients following the two-drug regimen (142+/-150 vs. 102+/-60 h, P<0.05). Chest physiotherapy (CP) and bronchodilatators (BD) were prescribed in 72% and 54% of cases, respectively (median duration 10 days). Conclusions: The variations observed in the clinical management of CAP inpatients were not in agreement with published guidelines. The overuse of a two-drug regimen, CP, and BD necessitates the development and implementation of evidence-based guidelines proposing detailed steps for the management of CAP inpatients.